This Is Why the Insurance Company Is Auditing You

About 50% of federal healthcare fraud indictments are the result of an underestimated healthcare audit. Physicians, dentists, psychiatrists, and other medical providers must realize a paradigm shift in healthcare audits. Previously, being audited was a normal occurrence that every provider would go through at some point in their medical careers. Today, this article, co-written by former prosecutors from the U.S. Department of Justice healthcare fraud section, will show that audits are more commonly targeted and designed to address those clinics and providers that were already determined to be under fraud suspicion.

The difference is important. If you receive a request for patient files, there is a good chance that the request is the result of an internal review process, not a random selection. Nowadays, CMS, Medicaid, Medicare, and increasingly private insurance companies follow the data-analysis model. In essence, computers calculate and analyze who should be audited, rather than the more lottery-type random approach previously utilized.

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Dr. Nick Oberheiden

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John W. Sellers

Former Senior Trial Attorney U.S. Department of Justice

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Joanne Fine DeLena

Former Assistant U.S. Attorney

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Lynette S. Byrd

Former Assistant U.S. Attorney

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Amanda Marshall

Former U.S. Attorney

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Aaron L. Wiley

Former Federal Prosecutor

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Roger Bach

Former Special Agent (OIG)

Gamal Abdel-Hafiz

Former Supervisory Special Agent (FBI)

Chris Quick

Former Special Agent (FBI & IRS-CI)

Kevin M. Sheridan

Former Special Agent (FBI)

Ray Yuen

Former Supervisory Special Agent (FBI)

Dennis A. Wichern

Former Special Agent-in-Charge (DEA)

What Happens in a Healthcare Audit?

Stage 1: Origin of the Audit

The vast majority of healthcare audits originate from one of two things: a patient complaint or a computer analysis review. Patients have enormous credibility when they report fraud, waste, or abuse to a federal program administrator or private insurance. In particular, when the complaint is in writing, detailed, and specific, there will be almost no payor that will not initiate an inquiry. Providers aware of a (credible) patient threat should contact an attorney for at least a brief consultation to discuss the seriousness of the threat and to contemplate early countermeasures, as recommended. More difficult to tackle, because they occur without awareness or even suspicion of the provider, are audits that are computer-generated. In essence, government or insurance computer programs will create lists of which doctor in a given geographical area prescribes the most opioids, which dentist bills the highest amounts to Medicaid, and which psychiatrist sees more patients than any of the competitors. Such “outlier” calculations are tricky because once experienced lawyers get involved, they often notice that the government is comparing apples and oranges by comparing top-specialists in a certain field (e.g. vein surgeons) with regular orthopedic surgeons to (surprisingly) conclude that the vein surgeon bills more vein procedures than a regular surgeon.

Depending on the validity of the findings within the initial stage, the case is then assigned to an auditor or fraud investigator. The difference is critical. In the first case, the audit is likely computer generated and not signed by an identifiable individual. In the case of an assignment to a fraud investigator, the internal review resulted in a fraud suspicion and the audit is now prepared and handled by a fraud investigator. As the name connotes, the fraud investigator is tasked to unmask fraud and to possibly make consequential recommendations such as a referral to DOJ or an exclusion or payment suspension. It would be a fatal mistake to treat an audit signed by a fraud investigator as a routine inquiry. Similarly, if the audit request is computer produced, it is likely l that the computer analysis suggested that you are a billing outlier or display some other billing irregularity (frequency of a certain code, use of a certain code versus a lower code etc.).

Stage 3: Request for Certain Medical Records

It is only now that a provider becomes aware of the pending audit and review process. Either by mail or through personal delivery, CMS and other payors will notify a provider of the patient chart request. The first thing now to do is to consult with experienced audit defense lawyers. Again, there is very likely a reason you were selected. It may be because you are declared an “outlier” or because a patient complaint against you, either way, you should take audits and inspections of your practice serious. Oberheiden PC attorneys offer instant advice, including on weekends, in free and confidential consultations. There truly is no good reason not to make use of such a free consultation.

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Stage 4: Review of Audited Charts

After the provider has complied by responding to the audit with the requested documents and information, the auditor or investigator will assign the files to be reviewed internally by the applicable expert staff. This review period can last for an extensive period of time due to backlog and the voluminous, document-intensive nature of medical review. Oftentimes, however, the review is cursory and purposefully bent towards declination or downgrading of claims. More and more, we are seeing that the conclusions reached in the audits inappropriately discount certain services or underestimate medical necessity.

Each audit results in a decision. Should the provider be referred to law enforcement, are there grounds for recoupment, or can the provider be unflagged and continue its billing and medical practice?

No matter at what stage you contact us, be assured that the Oberheiden PC attorneys and former prosecutors will do everything in their power to accomplish your goal: to keep your license, to not be charged, to not be excluded from CMS or expelled from the insurance network. The earlier you call us, the more we can impact the outcome.

What Should I Do When I Get Audited?

The earlier an experienced attorney is involved in the process, the higher the chances that your audit can be concluded quickly and without any escalation. Don’t make the mistake and let the audit run its course and then wonder, often many months later, why you are asked for more patient charts or why suddenly you are under payment suspension or visited by investigators.

Put simply, you can save a lot of time, resources, and money to engage experienced counsel from the moment you receive an audit. The experienced attorneys at Oberheiden PC will enter into a dialogue with the auditors or investigators to find out first and foremost why you are being audited, in what stage the audit is, and what avenues exist to resolve the audit in an expedited manner.

Here Are a Few Examples of How We Resolved Tough Audits

Dentists

Many dentists call Oberheiden PC because they feel bullied by DentaQuest and other intermediaries, insurance companies, and Medicaid. We successfully represented dentists, pediatric dentists, dental groups, and oral surgeons in a variety of audits, almost all sharing some form of concerns, deficiencies, lacking x-rays, or poor documentation. Our team quickly coordinates with the auditors and, parallel to responding to the actual audit, conducts an internal audit to understand the reason for the audit and to assess the potential exposure first. Our compliance protocols have proven to be very helpful and a strong consideration for concluding even audits alleging lack of medical necessity (and non-provided but billed for services) discreetly.

Cardiologists

Cardiologists are classic targets of rigid healthcare audits. With high volume of Medicare patients, CMS and Medicare intermediaries frequently select cardiologists for allegedly excessive testing and medically unnecessary therapy and services. In one recent audit, Oberheiden PC attorneys were confronted with an audit already referred to the U.S. Attorney’s Office for conducting and billing for medically not indicated tests. Even though late in the process, our attorneys undid the mistakes made by the provider (who did not use any attorney for the original audit) and convinced the Justice Department in a number of presentations to not bring charges against the cardiologist.

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Psychologists

Mental health providers are often surprised to realize that they, too, are subject to audits and investigations. Even though they are less frequent and less prominent targets of billing audits, Oberheiden PC routinely intervenes to assist psychologists, LPCs, social workers, and psychiatrists to defend missing or incomplete notes, missing charts, or poor billing decisions. In a recent representation of a psychologist, Dr. Nick Oberheiden made sure his client passed the audit without a recoupment request and without a referral to law enforcement even though, as a starting point, the majority of patient files were either missing or incomplete.

Call the Trusted Attorneys of Oberheiden P.C. Today

The attorneys of Oberheiden offer decades of experience as former Department of Justice officials, former federal prosecutors in charge of escalated healthcare audits and fraud investigations, and as trusted advisors to hundreds of dentists, physicians, and mental health providers across the United States. Together with a team of billing and coding experts, Oberheiden P.C. should be your first choice to accomplish your audit goals: expedited resolution without any exposure to the licensing board or law enforcement! To speak with a member of our federal health care fraud defense team as soon as possible, call 888-680-1745 or tell us how to reach you online now.

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